http://dx.doi.org/10.1590/S0034-72992005000200005

ISpecialist in Otorhinolaryngology,
Physician with Hospital OtoclínicaIIGeneralist (Emergency physician)IIIJoint Professor, Medical School, Federal University of Ceará,
Head of the Service of Otorhinolaryngology

Epistaxis remains one of the most common otolaryngology
emergencies. Despite considerable interest in the subject, there is still no
consensus on the most appropriate primary therapeutic modality. AIM: The purpose of this study was to evaluate the bleeding source of
acute or recurrent epistaxis in adults. STUDY DESIGN: Clinical prospective. MATERIAL AND METHOD: Thirty adults patients with acute or recurrent epistaxis
were evaluated through the use of frontal light and endoscope for identification
of the bleeding source in the nasal cavity. RESULTS: Use of the nasal endoscope allowed diagnosis of the bleeding
site in all patients. CONCLUSION: A careful examination of the posterior nasal cavity allows
identification of the bleeding source in most patients and should be a routine
procedure.

Key words: epistaxis, nasal bleeding,
treatment.

INTRODUCTION

Not so many issues in Otolaryngology have so
deeply shifted their paradigms in the last decades as the treatment of epistaxis.
Terms like "untreatable epistaxis" and "conservative treatment" should be revised.
The main reason for this paradigm shift was the advent of nasal endoscopy. If
epistaxis was previously labeled as an "untreatable" condition and managed with
multiple nasal packing, ligature of the carotid and/or maxillary arteries1,2,
or even vessel embolization3, now they have shown to be easily diagnosed
and treated through nasosinusal endoscopic surgery. Treatments previously considered
"conservative", such as nasal packing seem much more traumatic, uncomfortable
and, in some cases, with higher risks4 than simple endoscopic procedures,
such as local cauterization or ligature of the sphenopalatine artery.

For effective therapeutic approach, it is crucial
that nasal vascularization and prevalent bleeding sources are better understood.
Ligature of the external carotid conducted by Hyde2 in 1935 was the
first vascular procedure for epistaxis control. Chandler1, in 1965
was the first to perform a ligature of the maxillary artery transantrally in
an attempt to intervene next to an intranasal bleeding site. Intranasal approaches
for epistaxis control were established after the first ligature of the sphenopalatine
artery using a microscope (Stamm, 1985)5 and an endoscope (Budrovich
and Saette, 1992)6. Since then, treatment of epistaxis under microscopic
or endoscopic magnification of the nasal cavity posterior segment became popular,
less threatening and reduced distress.

OBJECTIVE

This study aims at identifying the nasal cavity's
bleeding source of patients with active or recurrent epistaxis by means of nasal
videoendoscopy.

MATERIAL AND METHOD

A prospective study was conducted with 30 patients
with epistaxis who were assisted at the emergency otolaryngology service (Otoclinica
- Fortaleza, CE), in the period of January 2002 to August 2004. Ages ranged
from 32 to 68 years, with mean age of 52. The group of patients comprised 17
men (56.6%) and 13 women (43.3%). After clinical assessment, all patients were
initially examined by classical anterior rhinoscopy with frontal illumination,
while those whose bleeding sources were not identified were submitted to nasal
endoscopic evaluation. Bleeding sources were classified as: anterior or posterior;
from the lateral nasal wall or nasal septum.

RESULTS

Out of 30 patients assessed, 19 (63.2%) presented
bleeding in the posterior segment of the nasal cavity  14 (46.6%) in the nasal
septum and 5 (16.6%) in the lateral nasal wall. Out of 11 patients (36.6%) with
bleeding at the anterior segment of the nasal cavity, all bleedings were found
in the anterior nasal septum. No patients presented bleeding in the anterior
region of the lateral nasal wall or bilateral bleeding.

DISCUSSION

W. Messerklinger 7 was the first to
adopt nasal and paranasal endoscopic surgery, rendering further contributions
to otolaryngologists. Since 1985, this approach started to be broadly practiced
by Kennedy8 in the United States, and worldwide in the 90's.

In 1992, when Budrovich6 reported
the treatment of epistaxis by nasal endoscopy, several other studies were published.
The first articles on this technique for the control of epistaxis described
comprehensive maxillary antrostomy followed by removal of the posterior wall
of the maxillary sinus and ligature of pterygomaxillary fossa vessels (White,
1996). The improved approach was very radical concerning nasal vascularization,
although it did not play a direct effect over the intranasal bleeding source.
After various studies on anatomy micro-dissections of cadavers, ligatures of
sphenopalatine vessels to reach the nasal cavity9-13 were the following
step. The concept that vascular ligature is more effective when performed the
nearest possible to the bleeding source led nasal endoscopy to become the gold
standard approach for patients with epistaxis.

Regular use of clinical endoscopy during the
last decade amplified the knowledge on the etiology and treatment of epistaxis.
The bleeding source inside the nasal cavity could be more easily and accurately
identified. Moreover, other less invasive procedures, such as cauterization
of the bleeding source, could be done presenting high efficacy rates14.
Local cauterization of the bleeding spot, which was previously limited to anterior
portions of the nasal cavity, could be amplified to posterior regions, with
the advent of endoscopic visualization.

Clinical use of endoscopy showed that, except
for the anterior nasal septum as a bleeding source, the most frequent site of
epistaxis was the posterior portion and not the lateral wall of the nasal septum,
which is contrary to what was previously believed, but corroborates our casuistic
and the data in the literature available14,15. The literature also
emphasizes the importance of Woodruff's venous plexus, which corresponds to
less than 10% of the cases with posterior epistaxis.

These clinical observations corroborate reports
of highly effective cauterization of the sphenopalatine artery (and/or its branches:
posterior lateral and septum nasal artery) in the control of posterior epistaxis,
although it opens new possibilities for less invasive approaches by local cauterization
of the bleeding spot in the posterior nasal septum through endoscopic visualization,
which also presents high efficacy rates16,1.

CLOSING REMARKS

The nasal septum is the most frequent site for
posterior nasal bleeding. If the bleeding source is not identified by anterior
rhinoscopy, a nasal endoscopy is mandatory. Identification and cauterization
of the bleeding point under endoscopic magnification of the posterior nasal
septum becomes an effective and less invasive procedure, avoiding unnecessary
cauterization of the sphenopalatine artery.